anesthesia algorithm

1.
Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
1
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
LARYNGOSPASM
MODULE:
CRITICAL
INCIDENTS
TARGET:
ALL
ANAESTHETISTS
&
INTENSIVISTS
BACKGROUND:
Laryngospasm
is
a
common
complication
around
the
time
of
airway
handling
in
adults
and
in
paediatric
patients.
Junior
trainees
should
have
an
approach
to
managing
this
crisis,
and
it’s
potential
complications.
A
protocol
for
managing
this
process
has
been
published
as
an
appendix
to
the
Difficult
Airway
Society
Extubation
Guidelines,
along
with
the
further
potential
consequence
of
laryngospasm:
negative
pressure
pulmonary
oedema.
RELEVANT
AREAS
OF
THE
ANAESTHETIC
CURRICULUM
IG_BS_10
In
respect
of
airway
management:
• Demonstrates
optimal
patient
position
for
airway
management.
• Manages
airway
with
mask
and
oral/nasopharyngeal
airways
• Demonstrates
hand
ventilation
with
bag
and
mask
• Able
to
insert
and
confirm
placement
of
a
Laryngeal
Mask
Airway
• Demonstrates
correct
head
positioning,
direct
laryngoscopy
and
successful
nasal/oral
intubation
techniques.
• Confirms
correct
tracheal
tube
placement
• Demonstrates
correct
use
of
bougies
• Demonstrates
correct
securing
and
protection
of
LMAs/tracheal
tubes
during
movement,
positioning
and
transfer.
• Correctly
conducts
RSI
sequence
• Correctly
demonstrates
the
technique
of
cricoid
pressure
IG_BS_11
Demonstrates
correct
use
of
oropharyngeal,
laryngeal
and
tracheal
suctioning
IO_BS_07
Demonstrates
role
as
team
player
and
when
appropriate,
leader
in
the
intra-­‐operative
environment
IO_BS_08
Communicates
with
the
theatre
team
in
a
clear
unambiguous
style
IO_BS_09
Able
to
respond
in
a
timely
and
appropriate
manner
to
events
that
may
affect
the
safety
of
patients
[e.g.
Hypotension,
Massive
haemorrhage]
[S]
CI_BK_02
Unexpected
fall
in
SpO2
with
or
without
cyanosis
CI_BK_03
Unexpected
increase
in
peak
airway
pressure
CI_BK_13
Difficult/failed
mask
ventilation
CI_BK_17
Laryngospasm
CI_BK_19
Bronchospasm
CI_BS_01
Demonstrates
good
non-­‐technical
skills
such
as:
[effective
communication,
team-­‐working,
leadership,
decision-­‐making
and
maintenance
of
high
situation
awareness]
CI_BS_02
Demonstrates
the
ability
to
recognise
early
a
deteriorating
situation
by
careful
monitoring
CI_BS_03
Demonstrates
the
ability
to
respond
appropriately
to
each
incident
listed
above
CI_BS_04
Shows
how
to
initiate
management
of
each
incident
listed
above
CI_BS_05
Demonstrates
ability
to
recognise
when
a
crisis
is
occurring
CI_BS_06
Demonstrates
how
to
obtain
the
attention
of
others
and
obtain
appropriate
help
when
a
crisis
is
occurring
CI_IS_01
Demonstrates
leadership
in
resuscitation/simulation
when
practicing
response
protocols.
CI_IS_02
Demonstrates
appropriate
use
of
team
resources
when
practicing
response
protocols.

2. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
2
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
INFORMATION
FOR
FACULTY
LEARNING
OBJECTIVES:
• Consideration
of
appropriate
options
for
the
common
complication
of
airway
management
• Demonstration
of
recognition
and
a
logical,
structured
approach
to
managing
laryngospasm.
• An
approach
to
managing
the
post-­‐laryngospasm
complication
of
post-­‐obstructive
pulmonary
oedema.
SCENE
INFORMATION:
• Location:
Theatre
This
scenario
takes
place
at
the
end
of
an
operation
that
required
intubation
e.g.
laparascopic
cholecystectomy.
Following
extubation
in
theatre,
the
patient
develops
laryngospasm
signified
by
a
‘crowing’
stridor
and
a
rapid
desaturation.
Mask
ventilation
is
unsuccessful
and
the
participant
needs
to
adopt
strategies
to
break
the
larygospasm.
Following
management
of
the
laryngospasm,
the
patient
develops
negative
pressure
pulmonary
oedema
requiring
further
management.
EQUIPMENT
&
CONSUMABLES
PERSONS
REQUIRED
Manikin
–
on
theatre
trolley.
ETT
in
situ
–
IPPV.
Checked
anaesthetic
machine
Stocked
Airway
trolley
-­‐
Laryngoscopes
(2
x
Macintosh)
-­‐
ET
Tubes
(Various
Sizes)
-­‐
OP,
NP
and
Advanced
Supraglottic
airways
(iGels,
LMAs)
Working
suction
Theatre
drapes
(partially
obscuring
head
and
airway
of
mannequin)
Anaesthetic
junior
trainee
Anaesthetic
Assistant
Anaesthetic
Senior
Trainee
Surgeon
(optional)
Scrub
nurse
(optional)
PARTICIPANT
BRIEFING:
(TO
BE
READ
ALOUD
TO
PARTICIPANT)
You
are
the
anaesthetist
for
an
elective
Laparoscopic
Cholecystectomy.
Your
patient
is
Jennifer
Roberts,
a
woman
in
her
40’s.
She
has
a
background
of
Cholecystitis,
Gallstones
and
occasional
heart
burn.
Her
BMI
is
36.
She
is
allergic
to
Penicillin.
She
last
ate
at
2200
yesterday.
Please
proceed
as
appropriate,
‘VOICE
OF
MANIKIN’
BRIEFING:
Silent
whilst
intubated.
After
extubation,
a
regular
‘crowing’
noise
from
the
upper
airway
develops.
VOICE
OF
‘TELEPHONE
HELP
BRIEFING’
Help
will
arrive
as
soon
as
possible.

3. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
3
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
CONDUCT
OF
SCENARIO
• Recognise
crisis
occurring
• Attempt
mask
ventilation
with
CPAP.
• Suction
under
direct
vision
• Consider
dose
of
Propofol
and/or
Suxamethonium
• Call
for
help
• Consider
options:
Re-­‐anaesthetise
and/or
re-­‐paralyse
• Appropriate
choice
of
airway
management
either
LMA
insertion
or
re-­‐intubation
• Despite
LMA/ETT
insertion
and
adequate
ventilation,
SaO2
slow
to
recover
–
pulmonary
oedema:
Bilateral
crackles
and
Sa02
85%
• Unable
to
ventilate
or
reintubate
• Sao@
fall
to
50%
• Slow
to
recover
due
to
pulmonary
oedema
• Prepare
for
end
of
anaesthetic
• Suction
• Turn
off
Vapour
• FiO2
100%
Scenario
ends
with
adequate
plan
for
further
care
NORMAL
DIFFICULTY
HIGH
DIFFICULTY
EXPECTED
ACTIONS
EXPECTED
ACTIONS
RESOLUTION
• SaO2
recovers
fully
with
appropriate
airway
management
LOW
DIFFICULTY
A:
Extubated.
Laryngospasm.
Stridor.
B:
SpO2
fall
to
70%
over
2
minutes.
Can’t
intubate,
can’t
ventilate
settings.
C:
HR
increases
to
130
over
3
mins,
BP
90/55.
D:
GCS
remains
3/15.
EXTUBATION
A:
Intubated.
Drapes
partially
covering
face
and
airway
B:
IPPV.
FiO2
40%,
Vt
500mls,
Sa02
98%.
RR
14.
C:
HR
70.
BP
105/60.
D:
Eyes
closed
and
taped.
GCS
3/15.
E:
Surgery
ongoing.
Operation
finishing.
INITIAL
SETTINGS
• Recognise
further
crisis
occurring
• Reassessment
+
consider
differentials
• Appropriate
Rx
for
pulmonary
oedema
• Planning
for
further
post-­‐op
care
EXPECTED
ACTIONS
• Progress
along
failed
intubation
protocol,
incl.
Plan
D
Surgical
airway
• Recognition
&
Mx
Pulmonary
oedema
• ICU
handover
EXPECTED
ACTIONS

4. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
4
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
Penicillin
2200
yesterday
Neg
Hb
11.8
NAD
NAD
NAD
Abdo
USS
-­‐
Gallstones
No
previous
GAs
Recurrent
Cholecystitis
Gallstones
Occasional
Reflux
Increased
BMI
(36)
Unremarkable
MP
2,
mouth
opening
3cm,
slightly
limited
neck
Laparoscopic
Cholecystectomy
Jennifer
Roberts
15/06/1968
Consented
for
GA
and
local
anaesthetic
infiltration.
Risks
explained:
dental
damage,
sore
throat,
post-­‐op
nausea
and
vomiting.

5. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
5
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
DEBRIEFING
POINTS
FOR
FURTHER
DISCUSSION:
• Consideration
of
appropriate
options
for
the
common
complication
of
airway
management
• Demonstration
of
recognition
and
a
logical,
structured
approach
to
managing
laryngospasm.
• An
approach
to
managing
the
post-­‐laryngospasm
complication
of
post-­‐obstructive
pulmonary
oedema.
DEBRIEFING
RESOURCES
Difficult
Airway
Society
Guidelines
for
the
management
of
tracheal
extubation
(Mar
2012).
Appendix
1:
Laryngospasm,
and
Appendix
2:
Post-­‐obstructive
pulmonary
oedema.
Popat
M,
Mitchell
V,
Dravid
R,
Patel
A,
Swampillai
C,
Higgs
A
Anaesthesia
67(3)
318-­‐340.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-­‐2044.2012.07075.x/pdf
Crisis
Management
during
anaesthesia:
Laryngospasm
(2005).
Qual
Saf
Health
Care
2005;14:e3
Visvanathan
T,
Kluger
MT,
Webb
RK,
Westhorpe
RN
http://qualitysafety.bmj.com/content/14/3/e3.full
Laryngospasm
–
The
Best
Treatment
(1998).
Anaesthesiology
89(5)1293-­‐1294.
Larson
P
http://homepage.mac.com/changcy/downloads/laryngospasm.pdf

6. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
6
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
INFORMATION
FOR
PARTICIPANTS
KEY
POINTS:
• Consideration
of
appropriate
options
for
the
common
complication
of
airway
management
• Demonstration
of
recognition
and
a
logical,
structured
approach
to
managing
laryngospasm.
• An
approach
to
managing
the
post-­‐laryngospasm
complication
of
post-­‐obstructive
pulmonary
oedema.
RELEVANCE
TO
AREAS
OF
THE
ANAESTHETIC
CURRICULUM
IG_BS_10
In
respect
of
airway
management:
• Demonstrates
optimal
patient
position
for
airway
management.
• Manages
airway
with
mask
and
oral/nasopharyngeal
airways
• Demonstrates
hand
ventilation
with
bag
and
mask
• Able
to
insert
and
confirm
placement
of
a
Laryngeal
Mask
Airway
• Demonstrates
correct
head
positioning,
direct
laryngoscopy
and
successful
nasal/oral
intubation
techniques.
• Confirms
correct
tracheal
tube
placement
• Demonstrates
correct
use
of
bougies
• Demonstrates
correct
securing
and
protection
of
LMAs/tracheal
tubes
during
movement,
positioning
and
transfer.
• Correctly
conducts
RSI
sequence
• Correctly
demonstrates
the
technique
of
cricoid
pressure
IG_BS_11
Demonstrates
correct
use
of
oropharyngeal,
laryngeal
and
tracheal
suctioning
IO_BS_07
Demonstrates
role
as
team
player
and
when
appropriate,
leader
in
the
intra-­‐operative
environment
IO_BS_08
Communicates
with
the
theatre
team
in
a
clear
unambiguous
style
IO_BS_09
Able
to
respond
in
a
timely
and
appropriate
manner
to
events
that
may
affect
the
safety
of
patients
[e.g.
Hypotension,
Massive
haemorrhage]
[S]
CI_BK_02
Unexpected
fall
in
SpO2
with
or
without
cyanosis
CI_BK_03
Unexpected
increase
in
peak
airway
pressure
CI_BK_13
Difficult/failed
mask
ventilation
CI_BK_17
Laryngospasm
CI_BK_19
Bronchospasm
CI_BS_01
Demonstrates
good
non-­‐technical
skills
such
as:
[effective
communication,
team-­‐working,
leadership,
decision-­‐making
and
maintenance
of
high
situation
awareness]
CI_BS_02
Demonstrates
the
ability
to
recognise
early
a
deteriorating
situation
by
careful
monitoring
CI_BS_03
Demonstrates
the
ability
to
respond
appropriately
to
each
incident
listed
above
CI_BS_04
Shows
how
to
initiate
management
of
each
incident
listed
above
CI_BS_05
Demonstrates
ability
to
recognise
when
a
crisis
is
occurring
CI_BS_06
Demonstrates
how
to
obtain
the
attention
of
others
and
obtain
appropriate
help
when
a
crisis
is
occurring
CI_IS_01
Demonstrates
leadership
in
resuscitation/simulation
when
practicing
response
protocols.
CI_IS_02
Demonstrates
appropriate
use
of
team
resources
when
practicing
response
protocols.

7. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
7
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
WORKPLACE-­‐BASED
ASSESSMENTS
Basic
Level
WBPA’s
CIB_D01
Demonstrates
the
emergency
management
of
the
following
critical
incidents
in
simulation:
• Unexpected
hypoxia
with
or
without
cyanosis
• Unexpected
increase
in
peak
airway
pressure
Demonstrates
the
emergency
management
of
the
following
specific
conditions
in
simulation:
• Laryngospasm
• Bronchospasm
FURTHER
RESOURCES
Difficult
Airway
Society
Guidelines
for
the
management
of
tracheal
extubation
(Mar
2012).
Appendix
1:
Laryngospasm,
and
Appendix
2:
Post-­‐obstructive
pulmonary
oedema.
Popat
M,
Mitchell
V,
Dravid
R,
Patel
A,
Swampillai
C,
Higgs
A
Anaesthesia
67(3)
318-­‐340.
http://onlinelibrary.wiley.com/doi/10.1111/j.1365-­‐2044.2012.07075.x/pdf
Crisis
Management
during
anaesthesia:
Laryngospasm
(2005).
Qual
Saf
Health
Care
2005;14:e3
Visvanathan
T,
Kluger
MT,
Webb
RK,
Westhorpe
RN
http://qualitysafety.bmj.com/content/14/3/e3.full
Laryngospasm
–
The
Best
Treatment
(1998).
Anaesthesiology
89(5)1293-­‐1294.
Larson
P
http://homepage.mac.com/changcy/downloads/laryngospasm.pdf

8. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
8
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
PARTICIPANT
REFLECTION:
What
have
you
learnt
from
this
experience?
(Please
try
to
list
3
things)
How
will
your
practice
now
change?
What
other
actions
will
you
now
take
to
meet
any
identified
learning
needs?

9. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
9
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
PARTICIPANT
FEEDBACK
Date
of
training
session:...........................................................................................................................................
Profession
and
grade:...............................................................................................................................................
What
role(s)
did
you
play
in
the
scenario?
(Please
tick)
Primary/Initial
Participant
Secondary
Participant
(e.g.
‘Call
for
Help’
responder)
Other
health
care
professional
(e.g.
nurse/ODP)
Other
role
(please
specify):
Observer
Strongly
Agree
Agree
Neither
agree
nor
disagree
Disagree
Strongly
Disagree
I
found
this
scenario
useful
I
understand
more
about
the
scenario
subject
I
have
more
confidence
to
deal
with
this
scenario
The
material
covered
was
relevant
to
me
Please
write
down
one
thing
you
have
learned
today,
and
that
you
will
use
in
your
clinical
practice.
How
could
this
scenario
be
improved
for
future
participants?
(This
is
especially
important
if
you
have
ticked
anything
in
the
disagree/strongly
disagree
box)

10. Anaesthesia
>
Critical
Incidents
>
Scenario
4
(BL)
Version
9
–
May
2015
10
Editor:
Dr
Andrew
Darby
Smith
Original
Author:
Dr
P
Shanmuha
FACULTY
DEBRIEF
–
TO
BE
COMPLETED
BY
FACULTY
TEAM
What
went
particularly
well
during
this
scenario?
What
did
not
go
well,
or
as
well
as
planned?
Why
didn’t
it
go
well?
How
could
the
scenario
be
improved
for
future
participants?